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Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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Zhu CY, Hong JC, Kamdar NV, Hu MY, Tseng CH, Lee JS, Kuo EJ, Yu R, Isorena J, Yeh MW, Livhits MJ. Comparison of preoperative alpha-blockade for resection of paraganglioma and pheochromocytoma. Endocr Pract 2022; 28:889-896. [PMID: 35809774 DOI: 10.1016/j.eprac.2022.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Phenoxybenzamine (nonselective, non-competitive alpha-blocker) is the preferred drug for preoperative treatment of pheochromocytoma, but doxazosin (selective, competitive alpha-blocker) may be equally effective. We compared the efficacy of doxazosin versus phenoxybenzamine. METHODS We conducted a prospective study of patients undergoing pheochromocytoma or paraganglioma resection by randomizing pretreatment with phenoxybenzamine or doxazosin at a single tertiary referral center. The high cost of phenoxybenzamine led to high crossover to doxazosin. Randomization was halted, and a consecutive historical cohort of phenoxybenzamine patients was included for a case-control study design. The efficacy of alpha-blockade was assessed with pre-induction infusion of incremental doses of phenylephrine. The primary outcomes were mortality, cardiovascular complications, and ICU admission. Secondary outcomes were hemodynamic instability index (proportion of operation outside of hemodynamic goals), adequacy of blockade by phenylephrine titration test, and drug costs. RESULTS Twenty-four patients were prospectively enrolled (doxazosin, n=20; phenoxybenzamine, n=4), and 15 historical patients treated with phenoxybenzamine were added (total phenoxybenzamine, n=19). No major cardiovascular complications occurred in either group. The phenylephrine dose-response curves showed less blood pressure rise in the phenoxybenzamine than the doxazosin group (linear regression coefficient 0.008 versus 0.018, P=.01), suggesting better alpha-blockade in the phenoxybenzamine group. Median hemodynamic instability index was 14% versus 13% in the phenoxybenzamine and doxazosin groups, respectively (P=.56). The median highest daily cost of phenoxybenzamine was $442.20 compared to $5.06 for doxazosin. CONCLUSION Phenoxybenzamine may blunt intraoperative hypertension better than doxazosin, but this difference did not translate to fewer cardiovascular complications and is offset by a considerably increased cost.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Joe C Hong
- Department of Anesthesiology, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Nirav V Kamdar
- Department of Anesthesiology, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Ming-Yeah Hu
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Jason S Lee
- Department of Anesthesiology, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Eric J Kuo
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Run Yu
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jennifer Isorena
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Michael W Yeh
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Masha J Livhits
- Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA.
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Yadav SK, Johri G, Jha CK, Jaiswal SK, Shekhar S, Kumar VV, Mishra SK. Pre-Operative Selective vs Non-Selective α-Blockade in Pheochromocytoma-Paraganglioma Patients Undergoing Surgery: A Meta-Analysis. Indian J Endocrinol Metab 2022; 26:4-12. [PMID: 35662758 PMCID: PMC9162260 DOI: 10.4103/ijem.ijem_469_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/02/2022] [Accepted: 02/06/2022] [Indexed: 11/04/2022] Open
Abstract
The main objective of this systematic review and meta-analysis was to review, assess and report on the studies that have evaluated selective alpha blockade (SAB) vs. non-selective alpha blockade (NSAB) therapy in patients undergoing surgery for pheochromocytomas and paragangliomas (PPGL). We performed a systematic search of electronic databases. A meta-analysis was conducted to examine the effectiveness of the two blockades. RevMan 5.3 was used for the meta-analysis. Of the eight articles that met the inclusion criteria, there was only one randomized control trial. Meta-analysis showed that there was no significant difference between the groups SAB and NSAB with regard to intra-operative systolic blood pressure (SBP) >160 mm Hg (relative risk (RR) 0.95 [95% CI 0.57, 1.56] P = 0·83) and intra-operative vasopressor requirement (RR 1.10 [95% CI 0.96, 1.26] P = 0·16). Meta-analysis revealed that there was a significant difference between the groups (SAB vs NSAB) with respect to post-operative vasopressor requirement (RR 1.66 [95% CI 1.0, 2.74] P = 0·05). There was no significant difference between the groups with respect to post-operative complications (RR 0.84 [95% CI 0.58, 1.22] P = 0·36). In conclusion, as patients blocked selectively may have a higher incidence of vasodilator requirement intra-operatively, NSAB offers some haemodynamic advantage over SAB. However, NSAB's real clinical benefit cannot be ascertained with the current studies as this difference did not result in any significant advantage over SAB with regard to morbidity or mortality.
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Affiliation(s)
- Sanjay K. Yadav
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Goonj Johri
- Department of Breast Surgery, Wythenshawe Hospital and Nightingale Breast Centre, Manchester University Foundation Trust, United Kingdom
| | - Chandan K. Jha
- Department of Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Saket Shekhar
- Department of Biostatistics, All India Institute of Medical Sciences, Patna, Bihar, India
| | - Vivek V. Kumar
- Department of Surgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Saroj K. Mishra
- Department of Endocrine Surgery, SGPGIMS, Lucknow, Uttar Pradesh, India
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4
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Kong H, Li N, Yang XC, Nie XL, Tian J, Wang DX. Nonselective Compared With Selective α-Blockade Is Associated With Less Intraoperative Hypertension in Patients With Pheochromocytomas and Paragangliomas: A Retrospective Cohort Study With Propensity Score Matching. Anesth Analg 2021; 132:140-149. [PMID: 32675634 PMCID: PMC7717474 DOI: 10.1213/ane.0000000000005070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Both selective and nonselective α-blockade are used for preoperative preparation in patients with pheochromocytomas and paragangliomas (PPGLs). However, the effects of different types of α-blockade on perioperative outcomes remain inconclusive. This study was designed to assess the association between the choice of α-blockade and the amount of intraoperative hypertension in patients undergoing surgery for PPGLs. METHODS: In this propensity-matched retrospective cohort study, data of patients who received either selective or nonselective α-blockade preoperatively and underwent surgery for PPGLs were collected. The primary end point was the time-weighted average above the systolic blood pressure (SBP) of 160 mm Hg (TWA-SBP >160 mm Hg), which was calculated as the total area of the SBP-time curve above the SBP of 160 mm Hg and divided by anesthesia duration. RESULTS: A total of 286 patients were included in analysis; of them, 156 received selective α-blockade and 130 nonselective α-blockade. After propensity score matching, 89 patients remained in each group. Patients who received nonselective α-blockade had a lower TWA-SBP >160 (median 0.472 mm Hg, interquartile range [IQR], 0.081–1.300) versus those who received selective α-blockade (median 1.114 mm Hg, IQR, 0.162–2.853; median difference −0.391, 95% confidence interval [CI], −0.828 to −0.032; P = .016); they also had a lower highest SBP during surgery (193 ± 24 mm Hg versus 205 ± 34 mm Hg; mean difference −12, 95% CI, −20 to −3; P = .008). Postoperative outcomes did not differ significantly between the 2 groups. CONCLUSIONS: For patients undergoing surgery for PPGLs, preoperative nonselective α-blockade was associated with less intraoperative hypertension when compared with selective α-blockade.
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Affiliation(s)
- Hao Kong
- From the Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Nan Li
- From the Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xi-Chun Yang
- From the Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Xiao-Lu Nie
- Centre for Clinical Epidemiology & Evidence-Based Medicine, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Jie Tian
- Department of Urology, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- From the Departments of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
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5
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Berends AMA, Kerstens MN, Lenders JWM, Timmers HJLM. Approach to the Patient: Perioperative Management of the Patient with Pheochromocytoma or Sympathetic Paraganglioma. J Clin Endocrinol Metab 2020; 105:5868468. [PMID: 32726444 DOI: 10.1210/clinem/dgaa441] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/06/2020] [Indexed: 02/04/2023]
Abstract
Pheochromocytomas and sympathetic paraganglioma (PPGL) are rare chromaffin cell tumors originating in the adrenal medulla and sympathetic paraganglia, respectively, which share the capacity to synthesize and release catecholamines. The incidence of PPGL has increased in recent years. Surgical resection is the only curative treatment for PPGL. Management of patients with PPGL is complex and should be done by a specialized multidisciplinary team in centers with broad expertise. Surgical resection of a PPGL is a high-risk procedure for which optimal pretreatment with antihypertensive drugs is required in combination with state-of-the-art surgical procedures and anesthesiological techniques. In this article we discuss the underlying evidence and the pros and cons of presurgical medical preparation. Finally, the areas of uncertainty and controversies in this field are addressed.
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Affiliation(s)
- Annika M A Berends
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jacques W M Lenders
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medicine III, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Henri J L M Timmers
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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6
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Ma L, Shen L, Zhang X, Huang Y. Predictors of hemodynamic instability in patients with pheochromocytoma and paraganglioma. J Surg Oncol 2020; 122:803-808. [PMID: 32562589 PMCID: PMC7496938 DOI: 10.1002/jso.26079] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Intraoperative hemodynamic instability is common in patients with pheochromocytoma and paraganglioma. The aim of this study was to identify the predictive risk factors of intraoperative hemodynamic instability. METHODS A total of 428 patients having elective resection of pheochromocytoma and/or paraganglioma at Peking Union Medical College Hospital between January 2014 and July 2019 were included. The association between preoperative parameters and the incidence of intraoperative hemodynamic instability were evaluated. Binary logistic regression was used to assess the predictive risk factors of hemodynamic instability. RESULTS Patients with intraoperative hemodynamic instability were more prone to have elevated levels of norepinephrine and epinephrine. Binary Logistic regression showed the risk factors of hemodynamic instability were tumor size >5.0 cm (odds ratio [OR], 1.889; 95% confidence interval [CI], 1.243-2.870; P = .003) and five-fold increases of urine epinephrine (OR, 2.195; 95% CI, 1.242-3.880; P = .007). CONCLUSIONS Intraoperative hemodynamic instability is common despite adequate preoperative medical treatment. Tumor size and high level of urinary epinephrine are tumor-related factors for intraoperative hemodynamic instability. Identifying these factors can help clinicians to manage patients more effectively and improve patients' outcomes.
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Affiliation(s)
- Lulu Ma
- Department of AnesthesiologyPeking Union Medical College HospitalBeijingChina
| | - Le Shen
- Department of AnesthesiologyPeking Union Medical College HospitalBeijingChina
| | - Xiuhua Zhang
- Department of AnesthesiologyPeking Union Medical College HospitalBeijingChina
| | - Yuguang Huang
- Department of AnesthesiologyPeking Union Medical College HospitalBeijingChina
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7
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Buitenwerf E, Osinga TE, Timmers HJLM, Lenders JWM, Feelders RA, Eekhoff EMW, Haak HR, Corssmit EPM, Bisschop PHLT, Valk GD, Veldman RG, Dullaart RPF, Links TP, Voogd MF, Wietasch GJKG, Kerstens MN. Efficacy of α-Blockers on Hemodynamic Control during Pheochromocytoma Resection: A Randomized Controlled Trial. J Clin Endocrinol Metab 2020; 105:5622983. [PMID: 31714582 PMCID: PMC7261201 DOI: 10.1210/clinem/dgz188] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/27/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Pretreatment with α-adrenergic receptor blockers is recommended to prevent hemodynamic instability during resection of a pheochromocytoma or sympathetic paraganglioma (PPGL). OBJECTIVE To determine which type of α-adrenergic receptor blocker provides the best efficacy. DESIGN Randomized controlled open-label trial (PRESCRIPT; ClinicalTrials.gov NCT01379898). SETTING Multicenter study including 9 centers in The Netherlands. PATIENTS 134 patients with nonmetastatic PPGL. INTERVENTION Phenoxybenzamine or doxazosin starting 2 to 3 weeks before surgery using a blood pressure targeted titration schedule. Intraoperative hemodynamic management was standardized. MAIN OUTCOME MEASURES Primary efficacy endpoint was the cumulative intraoperative time outside the blood pressure target range (ie, SBP >160 mmHg or MAP <60 mmHg) expressed as a percentage of total surgical procedure time. Secondary efficacy endpoint was the value on a hemodynamic instability score. RESULTS Median cumulative time outside blood pressure targets was 11.1% (interquartile range [IQR]: 4.3-20.6] in the phenoxybenzamine group compared to 12.2% (5.3-20.2)] in the doxazosin group (P = .75, r = 0.03). The hemodynamic instability score was 38.0 (28.8-58.0) and 50.0 (35.3-63.8) in the phenoxybenzamine and doxazosin group, respectively (P = .02, r = 0.20). The 30-day cardiovascular complication rate was 8.8% and 6.9% in the phenoxybenzamine and doxazosin group, respectively (P = .68). There was no mortality after 30 days. CONCLUSIONS The duration of blood pressure outside the target range during resection of a PPGL was not different after preoperative treatment with either phenoxybenzamine or doxazosin. Phenoxybenzamine was more effective in preventing intraoperative hemodynamic instability, but it could not be established whether this was associated with a better clinical outcome.
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Affiliation(s)
- Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Correspondence and Reprint Requests: Edward Buitenwerf, MD, Department of Endocrinology (AA31), University of Groningen, University Medical Center Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands. E-mail:
| | - Thamara E Osinga
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henri J L M Timmers
- Department of Internal Medicine, Section of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacques W M Lenders
- Department of Internal Medicine, Section of Vascular Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medicine III, Technische Universität Dresden, Dresden, Germany
| | - Richard A Feelders
- Department of Internal Medicine, Section of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Elisabeth M W Eekhoff
- Department of Internal Medicine, Endocrinology Section, Amsterdam University Medical Centers, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Harm R Haak
- Department of Internal Medicine, Máxima Medical Center, Eindhoven, The Netherlands
- Department of Internal Medicine, Division of General Internal Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
- Maastricht University, CAPHRI School for Public Health and Primary Care, Ageing and Long-Term Care, Maastricht, The Netherlands
| | - Eleonora P M Corssmit
- Department of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter H L T Bisschop
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerlof D Valk
- Department of Endocrine Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Magiel F Voogd
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Götz J K G Wietasch
- Department of Anesthesiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Conzo G, Musella M, Corcione F, Depalma M, Stanzione F, Della-Pietra C, Palazzo A, Napolitano S, Pasquali D, Milone M, Agostino-Sinisi A, Ferraro F, Santini L. Role of Preoperative Adrenergic Blockade with Doxazosin on Hemodynamic Control during the Surgical Treatment of Pheochromocytoma: A Retrospective Study of 48 Cases. Am Surg 2020. [DOI: 10.1177/000313481307901125] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Authors evaluated the effects of selective adrenergic blockade by means of doxazosin on blood pressure in 48 patients operated on for pheochromocytoma by a multicenter retrospective study. Age, tumor size, surgical approach, and operative time were analyzed as predictive factors of intraoperative hypertensive crises. Forty-eight patients underwent adrenalectomy—four open surgery and 44 laparoscopic surgery—for pheochromocytoma of adrenal glands from 1998 to 2008 after preoperative administration of doxazosin. Perioperative cardiovascular status modifications and surgical medium- and long-term outcomes were analyzed. There was no mortality, conversion rate was 4.5 per cent, and morbidity rate was 8.3 per cent. Intraoperative hypertensive crises (180/ 90 mmHg or higher) were observed in 14.5 per cent (seven of 48) of patients and were treated pharmacologically with no aftermath. None of the examined variables influenced the occurrence of intraoperative hypertensive episodes. Postoperative hypotension (lower than 90/60 mmHg) was observed in four of 48 patients (8.3%) and was treated by crystalloids and hydrocortisone. In the surgical treatment of pheochromocytoma, the preoperative adrenergic blockade by doxazosin does not prevent intraoperative hypertensive crises. Nevertheless, in our series, they were of short duration and were not associated with major cardiovascular complications. Perioperative hemodynamic instability was managed bypreoperative pharmacological treatment, allowing low morbidity.
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Affiliation(s)
- Giovanni Conzo
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Mario Musella
- Department of Surgery, Orthopedics, Trauma and Emergency, University of Naples “Federico II,” Naples, Italy; the
| | - Francesco Corcione
- Department of General and Laparoscopic Surgery, Monaldi Hospital, Naples, Italy; the
| | - Maurizio Depalma
- Department of General and Specialistic Surgery, Cardarelli Hospital, Naples, Italy; the
| | - Francesco Stanzione
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Cristina Della-Pietra
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Antonietta Palazzo
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Salvatore Napolitano
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
| | - Daniela Pasquali
- Division of Endocrinology, Second University of Naples, Naples, Italy
| | - Marco Milone
- Department of Surgery, Orthopedics, Trauma and Emergency, University of Naples “Federico II,” Naples, Italy; the
| | | | - Fausto Ferraro
- Anesthesiology and Intensive Care, Second University of Naples, Naples, Italy
| | - Luigi Santini
- Department of Anesthesiologic, Surgical and Emergency Science, VII Division of General Surgery Second University of Naples, Naples, Italy; the
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Affiliation(s)
- James K Moon
- Department of Surgery, The Mount Sinai Hospital, New York, NY
| | - Peter Mattei
- General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia.
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Zhao J, Ma W, Xie J, Dai J, Huang X, Fang C, He W, Sun F. Laparoscopic Treatment of Large Adrenal Tumor is Safe and Effective? A Single Center Experiences. J INVEST SURG 2020; 34:957-962. [PMID: 32036714 DOI: 10.1080/08941939.2020.1719243] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The comparisons between open surgery and minimally invasive surgery for treatment of large adrenal tumor (LAT) are still lacking. In this study, we attempted to explore the safety and effectiveness of laparoscopic treatment of LAT by comparing the outcomes between open adrenalectomy (OA) and laparoscopic adrenalectomy (LA). METHODS From 2003 to 2018, 78 LAT patients underwent tumor resection by OA or LA method at a single academic institution. Data were retrospectively collected and analyzed. RESULTS The median largest diameter of LAT was 10.0 (IQR 9.0-13.4) cm. The median operation time in OA group was 215 (IQR 180-240) min versus 180 (IQR 135-245) min in LA group (P = 0.042). The median blood loss in OA group was 1000 (IQR 625-1500) ml versus 200 (IQR 100-700) ml in LA group (P < 0.001). The median Clavien-Dindo score in OA group was 2 (IQR 2-4) versus 0 (IQR 0-4) in LA group (P = 0.035). On univariate and multivariate analysis, the largest diameter of tumor was significantly associated with operation time, blood loss, and recovery time (P < 0.05). CONCLUSIONS Laparoscopic treatment of LAT was found to be safe and feasible in experienced hands and can replace open surgeries in most cases.
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Affiliation(s)
- Juping Zhao
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Wenming Ma
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Jialing Xie
- Department of Pathology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Jun Dai
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Xin Huang
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Chen Fang
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Wei He
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
| | - Fukang Sun
- Department of Urology, Shanghai JiaoTong University School of Medicine, Ruijin Hospital, Shanghai, China
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11
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Fang F, Ding L, He Q, Liu M. Preoperative Management of Pheochromocytoma and Paraganglioma. Front Endocrinol (Lausanne) 2020; 11:586795. [PMID: 33117294 PMCID: PMC7551102 DOI: 10.3389/fendo.2020.586795] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/14/2020] [Indexed: 01/10/2023] Open
Abstract
Pheochromocytoma and paraganglioma (PPGL) are rare neuroendocrine tumors, characterized by excessive release of catecholamines (CAs), and manifested as the classic triad of headaches, palpitations, profuse sweating, and a variety of other signs and symptoms. The diagnosis of PPGL requires both evidence of excessive release of CAs and anatomical localization of CA-secreting tumor. Surgery is the mainstay of treatment for all patients with PPGL unless contraindicated. However, without proper preparation, the release of excessive CAs, especially during surgery, can result in lethal cardiovascular complications. Herein, we briefly reviewed the pathogenesis of this disease, discussed the current approaches and evidence available for preoperative management, summarizing the results of the latest studies which compared the efficacies of preoperative management with or without α adrenergic-receptor antagonists, aiming to facilitate better understanding of the preoperative management of PPGL for the physicians.
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12
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Extreme and Cyclical Blood Pressure Elevation in a Pheochromocytoma Hypertensive Crisis. Case Rep Endocrinol 2018; 2018:4073536. [PMID: 30112225 PMCID: PMC6077531 DOI: 10.1155/2018/4073536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/23/2018] [Accepted: 07/05/2018] [Indexed: 11/18/2022] Open
Abstract
Pheochromocytomas are rare adrenal neoplasms characterized by excess secretion of catecholamines. We describe the case of a 65-year-old man, known for hypertension, with no family history of hereditary pheochromocytoma syndromes. He reported a two-year history of flushing, systolic blood pressure surges to 200 mmHg, headaches, tremors, and syncope. His initial workup revealed elevated 24h urine catecholamines and metanephrines. An adrenal MRI in March 2017 showed a large 7.6 cm heterogeneous right adrenal lesion. Given orthostatic hypotension, his final preoperative dose was limited to a low dose of terazosin and metoprolol. In the operating room, shortly after intubation and Foley insertion, his blood pressure rose to 350 mmHg. Surgery was cancelled and he was admitted to the intensive care unit, where intravenous phentolamine, nitroprusside, and nicardipine were started. His systolic blood pressure would oscillate between 60 mmHg and 350 mmHg at 2-3 minutes' intervals. After 3 days, he was weaned off intravenous medications. His oral medications were uptitrated to high doses of phenoxybenzamine, metoprolol, and nifedipine. Three weeks later, he underwent successful open right adrenalectomy. This case outlines the importance of preoperative preparation of pheochromocytomas and raises the question if phenoxybenzamine is the alpha-blocker of choice for larger tumours with significant hormonal secretion.
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Conzo G, Gambardella C, Candela G, Sanguinetti A, Polistena A, Clarizia G, Patrone R, Di Capua F, Offi C, Musella M, Iorio S, Bellastella G, Pasquali D, De Bellis A, Sinisi A, Avenia N. Single center experience with laparoscopic adrenalectomy on a large clinical series. BMC Surg 2018; 18:2. [PMID: 29325527 PMCID: PMC5765650 DOI: 10.1186/s12893-017-0333-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 12/26/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Laparoscopic adrenalectomy is considered the gold standard technique for the treatment of benign small and medium size adrenal masses (<6 cm), due to low morbidity rate, short hospitalization and patient rapid recovery. The aim of our study is to analyse the feasibility and efficiency of this surgical approach in a broad spectrum of adrenal gland pathologies. METHODS Pre-operative, intra-operative and post-operative data from 126 patients undergone laparoscopic adrenalectomy between January 2003 and December 2015 were retrospectively collected and reviewed. Diagnosis was obtained on the basis of clinical examination, laboratory values and imaging techniques. Doxazosin was preoperatively administered in case of pheochromocytoma while spironolactone and potassium were employed to treat Conn's disease. Laparoscopic adrenalectomies were all performed by the same surgeon (CG). First 30 procedures were considered as learning curve adrenalectomies. RESULTS One hundred twenty-six patients were included in the study. Functioning tumors were diagnosed in 84 patients, 27 patients were affected by pheochromocytomas, 29 by Conn's disease, 28 by Cushing disease. Surgery mean operative time was 137.33 min (range 100-180) during the learning curve adrenalectomies and 96.5 min (range 75-110) in subsequent procedures. Mean blood loss was respectively 160.2 ml (range 60-280) and 90.5 ml (range 50-200) in the first 30 procedures and the subsequent ones. Only one conversion to open surgery occurred. No post-operative major complications were observed, while minor complications occurred in 8 patients (0,79%). In 83 out of 84 functioning neoplasms, laparoscopic adrenalectomy was effective in normalization of endocrine profile. CONCLUSIONS Laparoscopic adrenalectomy is a safe and feasible procedure, even for functioning masses and pheochromocytomas. A multidisciplinary team including endocrinologists, endocrine surgeons and anaesthesiologists, is recommended in the management of adrenal pathology, and adrenal surgery should be performed in referral high volume centers. A thirty-procedures learning curve is recommended to improve surgical outcomes.
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Affiliation(s)
- Giovanni Conzo
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Claudio Gambardella
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Giancarlo Candela
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Alessandro Sanguinetti
- Endocrine Surgery Unit, University of Perugia, Piazza dell’Università, 06123 Perugia, Italy
| | - Andrea Polistena
- Endocrine Surgery Unit, University of Perugia, Piazza dell’Università, 06123 Perugia, Italy
| | - Guglielmo Clarizia
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Renato Patrone
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Francesco Di Capua
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Chiara Offi
- Division of General and Oncologic Surgery, Department of Cardiothoracic and Respiratory Sciences, University of Campania “Luigi Vanvitelli”, Via Pansini 5, 80131 Naples, Italy
| | - Mario Musella
- Advanced Biomedical Sciences Department, Federico II University, Napoli, Italy
| | - Sergio Iorio
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Giseppe Bellastella
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Daniela Pasquali
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Annamaria De Bellis
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Antonio Sinisi
- Department of Medical, Surgical, Neurological, Metabolic and Aging Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
| | - Nicola Avenia
- Endocrine Surgery Unit, University of Perugia, Piazza dell’Università, 06123 Perugia, Italy
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Liu C, Lv Q, Chen X, Ni G, Hu L, Tong N, Zhang Y. Preoperative selective vs non-selective α-blockade in PPGL patients undergoing adrenalectomy. Endocr Connect 2017; 6:830-838. [PMID: 28986400 PMCID: PMC5682411 DOI: 10.1530/ec-17-0232] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 10/05/2017] [Indexed: 02/05/2023]
Abstract
PURPOSE Preoperative preparation for adrenalectomy for pheochromocytomas and paragangliomas (PPGL) is universally recognized as necessary, while the optimal strategy remains controversial. Our aims were to increase intraoperative hemodynamic stability, expedite postoperative recovery, decrease side effects and reduce costs for patients with PPGL undergoing adrenalectomy. METHODS We identified 526 patients undergoing open adrenalectomy for PPGL in the West China Hospital of Sichuan University between May, 2007 and December, 2016. 149 patients received preoperative selective α-blockade with phenoxybenzamine, and 377 patients received non-selective α-blockade with prazosin, doxazosin or terazosin. There were no statistical differences between groups regarding preoperative patient and tumor characteristics. Operations were planned once hypertensive patients were well-controlled with blood pressure ≤130/85 mmHg. Intraoperatively, all patients received arterial blood pressure monitoring, and indwelling urinary catheters to record urine output. We recorded intraoperative hemodynamics, status in the postanesthesia or intensive care unit, postoperative recovery and complications. RESULTS Patients in the non-selective group showed a more significant decline in postoperative systolic blood pressure than the selective group (P = 0.041). Also, patients in the non-selective group appeared to receive a long-term anti-hypertensive effect, especially for diastolic blood pressure (P = 0.037), which was a novel finding, based on the current literature. CONCLUSIONS Our results confirmed that non-selective α-blockade produced a more significant anti-hypertensive effect than selective α-blockade. However, we found no significant difference in intraoperative hemodynamic instability, postoperative recovery and postoperative complications between groups.
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Affiliation(s)
- Caojie Liu
- West China Hospital, Sichuan University, Chengdu, China
| | - Qingguo Lv
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Xinlei Chen
- West China Hospital, Sichuan University, Chengdu, China
| | - Guangcheng Ni
- West China Hospital, Sichuan University, Chengdu, China
| | - Liru Hu
- West China Hospital, Sichuan University, Chengdu, China
| | - Nanwei Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
| | - Yuwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, China
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Abstract
Ectopic pheochromocytoma (EP) is considered as pheochromocytoma located at extra-adrenal site. Surgical removal is believed to be the best choice for treatment of pheochromocytoma. We present a series EP resected by laparoscopic approach (LEP) and confirm its feasibility. We retrospectively reviewed clinical data of 4 patients underwent laparoscopic resection of LEP (periaortocaval EP, n = 1; retroperitoneal EP, n = 2; bladder EP, n = 1), which was collected and analyzed retrospectively in Zhejiang Provincial People's Hospital. The tumors were all successfully resected by laparoscopic approach, and there was no one conversed to open surgery or needing blood transfusion. Laparoscopic resection is a feasible and safe choice for EP.
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Affiliation(s)
- Hanhui Cai
- Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
- Department of Second Clinical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuhua Zhang
- Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zhiming Hu
- Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
- Address correspondence to: Dr. Zhiming Hu, Department of Hepatobiliary, Pancreatic and Minimally Invasive Surgery, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou 310014, China. E-mail:
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Bholah R, Bunchman TE. Review of Pediatric Pheochromocytoma and Paraganglioma. Front Pediatr 2017; 5:155. [PMID: 28752085 PMCID: PMC5508015 DOI: 10.3389/fped.2017.00155] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 06/26/2017] [Indexed: 01/01/2023] Open
Abstract
Pheochromocytoma (PCC) and paraganglioma (PGL) are rare chromaffin cell tumors which secrete catecholamines and form part of the family of neuroendocrine tumors. Although a rare cause of secondary hypertension in pediatrics, the presentation of hypertension in these patients is characteristic, and treatment is definitive. The gold standard for diagnosis is via measurement of plasma free metanephrines, with imaging studies performed for localization, identification of metastatic lesions and for surgical resection. Preoperative therapy with alpha-blocking agents, beta blockers, and potentially tyrosine hydroxylase inhibitors aid in a safe pre-, intra- and postoperative course. PCC and PGL are inherited in as much as 80% of pediatric cases, and all patients with mutations should be followed closely given the risk of recurrence and malignancy. While the presentation of chromaffin cell tumors has been well described with multiple endocrine neoplasia, NF1, and Von Hippel-Lindau syndromes, the identification of new gene mutations leading to chromaffin cell tumors at a young age is changing the landscape of how clinicians approach such cases. The paraganglioma-pheochromocytoma syndromes (SDHx) comprise familial gene mutations, of which the SDHB gene mutation carries a high rate of malignancy. Since the inheritance rate of such tumors is higher than previously described, genetic screening is recommended in all patients, and lifelong follow-up for recurrent tumors is a must. A multidisciplinary team approach allows for optimal health-care delivery in such children. This review serves to provide an overview of pediatric PCC and PGL, including updates on the preferred methods of imaging, guidelines on gene testing as well as management of hypertension in such patients.
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Affiliation(s)
- Reshma Bholah
- Pediatric Nephrology, Virginia Commonwealth University, Richmond, VA, United States
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Ramachandran R, Rewari V. Factors affecting the haemodynamic behaviour of patients undergoing pheochromocytoma and paraganglioma removal: A review. Cardiovasc Endocrinol 2017; 6:73-80. [PMID: 31646123 PMCID: PMC6768518 DOI: 10.1097/xce.0000000000000090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/24/2016] [Indexed: 12/19/2022] Open
Abstract
Pheochromocytoma and paraganglioma are catecholamine-secreting tumours associated with major haemodynamic upheavals. The cardiovascular and other organ-related morbidity and even mortality has been ascribed to the major haemodynamic effects of these tumours. Many factors affect the nature and intensity of these haemodynamic changes. The rarity of these tumours as well as their extremely varied clinical presentation preclude conduct of randomized-controlled trials that may provide evidence in terms of these factors and the ways to predict and control them. Many retrospective studies and case reports, however, do provide some insight into their haemodynamic behaviour. Factors such as tumour pathology, associated genetic syndromes, anatomical attributes and perioperative drug therapy affect the haemodynamics of patients with these unique tumours. Knowledge of these factors and their presumed and known association with haemodynamic behaviour of the patients is important during the perioperative care of these patients. The review focuses on the tumour-related, patient-related and the perioperative care-related factors that affect the haemodynamic behaviour of these patients during the surgical removal of these tumours.
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Affiliation(s)
- Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical care, All India Institute of Medical Sciences, Delhi, India
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Lee H, Dominiczak AF, Jennings GLR, Cho EJ, Lee HY. Case of Chronic Indolent Pheochromocytoma That Caused Medically Controlled Hypertension but Treatment-Resistant Diabetes Mellitus. Hypertension 2017; 69:740-746. [PMID: 28373587 DOI: 10.1161/hypertensionaha.117.09183] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- HyunJung Lee
- From the Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea (H.J.L., H.-Y.L.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); and Division of Cardiology, St. Paul's Hospital, College of Medicine, The Catholic University, Seoul, Republic of Korea (E.J.C.)
| | - Anna F Dominiczak
- From the Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea (H.J.L., H.-Y.L.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); and Division of Cardiology, St. Paul's Hospital, College of Medicine, The Catholic University, Seoul, Republic of Korea (E.J.C.)
| | - Garry L R Jennings
- From the Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea (H.J.L., H.-Y.L.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); and Division of Cardiology, St. Paul's Hospital, College of Medicine, The Catholic University, Seoul, Republic of Korea (E.J.C.)
| | - Eun Joo Cho
- From the Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea (H.J.L., H.-Y.L.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); and Division of Cardiology, St. Paul's Hospital, College of Medicine, The Catholic University, Seoul, Republic of Korea (E.J.C.)
| | - Hae-Young Lee
- From the Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Republic of Korea (H.J.L., H.-Y.L.); Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, United Kingdom (A.F.D.); Baker IDI Heart and Diabetes Institute, Melbourne, Australia (G.L.R.J.); and Division of Cardiology, St. Paul's Hospital, College of Medicine, The Catholic University, Seoul, Republic of Korea (E.J.C.).
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Preoperative Levels of Catecholamines and Metanephrines and Intraoperative Hemodynamics of Patients Undergoing Pheochromocytoma and Paraganglioma Resection. Urology 2017; 100:131-138. [DOI: 10.1016/j.urology.2016.10.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/05/2016] [Accepted: 10/10/2016] [Indexed: 01/22/2023]
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20
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Randle RW, Balentine CJ, Pitt SC, Schneider DF, Sippel RS. Selective Versus Non-selective α-Blockade Prior to Laparoscopic Adrenalectomy for Pheochromocytoma. Ann Surg Oncol 2016; 24:244-250. [PMID: 27561909 DOI: 10.1245/s10434-016-5514-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND The optimal preoperative α-blockade strategy is debated for patients undergoing laparoscopic adrenalectomy for pheochromocytomas. We evaluated the impact of selective versus non-selective α-blockade on intraoperative hemodynamics and postoperative outcomes. METHODS We identified patients having laparoscopic adrenalectomy for pheochromocytomas from 2001 to 2015. As a marker of overall intraoperative hemodynamics, we combined systolic blood pressure (SBP) > 200, SBP < 80, SBP < 80 and >200, pulse > 120, vasopressor infusion, and vasodilator infusion into a single variable. Similarly, the combination of vasopressor infusion in the post-anesthesia care unit (PACU) and the need for intensive care unit (ICU) admission provided an overview of postoperative support. RESULTS We identified 52 patients undergoing unilateral laparoscopic adrenalectomy for pheochromocytoma. Selective α-blockade (i.e. doxazosin) was performed in 35 % (n = 18) of patients, and non-selective blockade with phenoxybenzamine was performed in 65 % (n = 34) of patients. Demographics and tumor characteristics were similar between groups. Patients blocked selectively were more likely to have an SBP < 80 (67 %) than those blocked with phenoxybenzamine (35 %) (p = 0.03), but we found no significant difference in overall intraoperative hemodynamics between patients blocked selectively and non-selectively (p = 0.09). However, postoperatively, patients blocked selectively were more likely to require additional support with vasopressor infusions in the PACU or ICU admission (p = 0.02). Hospital stay and complication rates were similar. CONCLUSION Laparoscopic adrenalectomy for pheochromocytoma is safe regardless of the preoperative α-blockade strategy employed, but patients blocked selectively may have a higher incidence of transient hypotension during surgery and a greater need for postoperative support. These differences did not result in longer hospital stay or increased complications.
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Affiliation(s)
- Reese W Randle
- Department of Surgery, University of Wisconsin, Madison, WI, USA.
| | | | - Susan C Pitt
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | | | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, WI, USA
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21
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Ramachandran R, Rewari V. Preoperative optimization in pheochromocytoma: phenoxybenzamine may be redundant but not alpha blockade. Can J Anaesth 2015; 63:629. [PMID: 26643509 DOI: 10.1007/s12630-015-0557-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 11/23/2015] [Accepted: 11/27/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India.
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Delhi, India
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22
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Anti-tumor activity of phenoxybenzamine hydrochloride on malignant glioma cells. Tumour Biol 2015; 37:2901-8. [PMID: 26409450 DOI: 10.1007/s13277-015-4102-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 09/14/2015] [Indexed: 12/18/2022] Open
Abstract
Phenoxybenzamine hydrochloride (PHEN) is a selective antagonist of both α-adrenoceptor and calmodulin that exhibits anticancer properties. The aim of this study was to explore the anti-tumor function of PHEN in glioma. Cell proliferation assay was used to assess glioma cell growth. Migration and invasion capacity of glioma cells was monitored by wound-healing and transwell assay, respectively. Neurosphere formation test was adopted for the tumorigenesis of glioma cells, which was also confirmed by soft agar cloning formation test in vitro and a nude mouse model in vivo. Finally, we explored the potential pathway utilized by PHEN using Western blot and immunofluoresce staining. PHEN exhibited a significant inhibitory effect on the proliferation of both U251 and U87MG glioma cell lines in a positive dose-dependent manner. PHEN apparently attenuated the malignancy of glioma in terms of migration and invasion and also suppressed the tumorigenic capacity both in vitro and in vivo. Mechanism study showed that PHEN promoted tumor suppression by inhibiting the TrkB-Akt pathway. The results of the present study demonstrated that PHEN suppressed the proliferation, migration, invasion, and tumorigenesis of glioma cells, induced LINGO-1 expression, and inhibited the TrkB-Akt pathway, which may prove to be the mechanisms underlying the anti-tumor effect of PHEN on glioma cells.
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Kiernan CM, Du L, Chen X, Broome JT, Shi C, Peters MF, Solorzano CC. Predictors of hemodynamic instability during surgery for pheochromocytoma. Ann Surg Oncol 2014; 21:3865-71. [PMID: 24939623 DOI: 10.1245/s10434-014-3847-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Resection of pheochromocytoma is often associated with hemodynamic instability (HDI). We examined patient and tumor factors that may influence HDI. The effect of pretreatment with nonselective α blockade phenoxybenzamine (PXB) versus selective α blockade on HDI and outcomes was also evaluated. METHODS The records of 91 patients who underwent adrenalectomy between 2002 and 2013 were retrospectively reviewed. HDI was determined by number of intraoperative episodes of systolic blood pressure (SBP) > 200 mmHg, those greater than or less than 30 % of baseline, heart rate > 110 bpm, and the need for postoperative vasopressors. Fishers exact, t test and regressions were performed. RESULTS Among 91 patients, 78 % received PXB, 18 % selective α blockade and 4 % no adrenergic blockade. Patient demographics, tumor factors and surgical approach were similar among the blockade groups. On multivariate analysis, increasing tumor size was associated with a significant rise in the number of episodes of SBP > 30 % [rate ratio (RR) 1.40] and an increased postoperative vasopressor requirement [odds ratio (OR) 1.23]. Open adrenalectomy and use of selective blockade were associated with an increased number of episodes of SBP > 200 mmHg (RR 27.8 and RR 20.9, respectively). Open adrenalectomy was also associated with increased readmissions (OR 12.3), complications (OR 5.6), use of postoperative vasopressors (OR 4.4) and hospital stay (4.6 days longer). There were no differences in other HDI measurements or postoperative outcomes among the blockade groups. CONCLUSIONS Tumor size, open adrenalectomy, and type of α blockade were associated with intraoperative HDI during pheochromocytoma resection. Selective blockade was associated with significantly more episodes of intraoperative hypertension but no perioperative adverse outcomes.
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Affiliation(s)
- Colleen M Kiernan
- Department of General Surgery, Vanderbilt University, Nashville, TN, USA,
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Conzo G, Pasquali D, Colantuoni V, Circelli L, Tartaglia E, Gambardella C, Napolitano S, Mauriello C, Avenia N, Santini L, Sinisi AA. Current concepts of pheochromocytoma. Int J Surg 2014; 12:469-74. [DOI: 10.1016/j.ijsu.2014.04.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 01/26/2014] [Accepted: 04/08/2014] [Indexed: 02/09/2023]
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25
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Hodin R, Lubitz C, Phitayakorn R, Stephen A. Diagnosis and management of pheochromocytoma. Curr Probl Surg 2014; 51:151-87. [DOI: 10.1067/j.cpsurg.2013.12.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 12/27/2013] [Indexed: 12/21/2022]
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Zhao J, Sun F, Jing X, Zhou W, Huang X, Wang H, Zhu Y, Yuan F, Shen Z. The diagnosis and treatment of primary adrenal lipomatous tumours in Chinese patients: A 31-year follow-up study. Can Urol Assoc J 2014; 8:E132-6. [PMID: 24678351 DOI: 10.5489/cuaj.977] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Adrenal lipomatous tumours (ALTs) are rarely encountered in clinical practice and consequently little is known about their clinical features. METHODS We analyze the clinical features, diagnosis and treatment of ALTs based on cases presenting at a single centre over a 31-year period. We reviewed clinical data from patients with primary adrenal tumours treated at the Ruijin Hospital, Shanghai between January 1980 and December 2010. RESULTS A total of 73 cases of primary ALTs in 22 men and 51 women (mean age 51.1±14.2 years) were reviewed. The ALTs included 65 myelolipomas (89.0%), 3 lipomas (4.1%), 2 angiomyolipomas (2.7%), 2 teratomas (2.7%), and 1 liposarcoma (1.4%). Of the total 73 patients, 24 of them had tumours in the left adrenal gland, 47 in the right gland and 2 had bilateral tumours. In total, 51 patients underwent open surgery and 22 laparoscopic surgery. CONCLUSION Myelolipoma is predominant among the various types of lipomatous adrenal gland tumours; it accounts for about 90% of all cases. Surgery is recommended for tumours ≥3.5 cm in diameter, for all cases of symptomatic tumour, and for cases of teratoma or liposarcoma identified by preoperative imaging.
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Affiliation(s)
- Juping Zhao
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Fukang Sun
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xiaolong Jing
- Department of Pathology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China Juping Zhao and Xin Huang contributed equally to this work
| | - Wenlong Zhou
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Xin Huang
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Haofei Wang
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Yu Zhu
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Fei Yuan
- Department of Pathology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China Juping Zhao and Xin Huang contributed equally to this work
| | - Zhoujun Shen
- Department of Urology, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
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Agrawal R, Mishra SK, Bhatia E, Mishra A, Chand G, Agarwal G, Agarwal A, Verma AK. Prospective Study to Compare Peri-operative Hemodynamic Alterations following Preparation for Pheochromocytoma Surgery by Phenoxybenzamine or Prazosin. World J Surg 2013; 38:716-23. [DOI: 10.1007/s00268-013-2325-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Conzo G, Pasquali D, Della Pietra C, Napolitano S, Esposito D, Iorio S, De Bellis A, Docimo G, Ferraro F, Santini L, Sinisi A. Laparoscopic adrenal surgery: ten-year experience in a single institution. BMC Surg 2013; 13 Suppl 2:S5. [PMID: 24267584 PMCID: PMC3850966 DOI: 10.1186/1471-2482-13-s2-s5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background Minimal invasive adrenalectomy has become the procedure of choice to treat adrenal tumors with a benign appearance, ≤ 6 cm in diameter and weighing < 100 g. Authors evaluated medium- and long-term outcomes of laparoscopic adrenalectomy (LA), performed for ten years in a single endocrine surgery unit. Methods We retrospectively reviewed 88 consecutive patients undergone LA for lesions of adrenal glands from 2003 to 2013. The first 30 operations were considered part of the learning curve. Doxazosin was preoperatively administered in case of pheochromocytoma (PCC), while spironolactone and potassium were employed to treat Conn's disease. Perioperative cardiovascular status modifications and surgical and medium- and long-term results were analyzed. Results Forty nine (55.68%) functioning tumors, and one (1.13%) bilateral adrenal disease were identified. In 2 patients (2.27%) a supposed adrenal metastasis was postoperatively confirmed, while in no patients a diagnosis of incidental primitive malignancy was performed. There was no mortality or major post operative complication. The mean operative time was higher during the learning curve. Conversion and morbidity rates were respectively 1.13% and 5.7%. Intraoperative hypertensive crises (≥180/90 mmHg) were observed in 23.5% (4/17) of PCC patients and were treated pharmacologically with no aftermath. There was no influence of age, size and operative time on the occurrence of PCC intraoperative hypertensive episodes. Surgery determined a normalization of the endocrine profile. One single PCC persistence was observed, while in a Conn's patient, just undergone right LA, a left sparing adrenalectomy was performed for a contralateral metachronous aldosteronoma. Conclusions LA, a safe, effective and well tolerated procedure for the treatment of adrenal neoplasms ≤ 6 cm, is feasible for larger lesions, with a similar low morbidity rate. Operative time has improved along with the increase of the experience and of the technological development. Preoperative adrenergic blockade did not prevent PCC intraoperative hypertensive crises, but facilitated the control of the hemodynamic stability.
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Ha JM, Kim JY, Oh TO, Rhee YS, Chi SC, Kuk H, Park CW, Park ES. Preparation and evaluation of sustained-release doxazosin mesylate pellets. Chem Pharm Bull (Tokyo) 2013; 61:371-8. [PMID: 23385960 DOI: 10.1248/cpb.c12-00767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Doxazosin mesylate (DXM) sustained release pellets were prepared by an extrusion-spheronization and fluid-bed coating technique. The core pellets containing DXM were prepared by extrusion-spheronization technique, and coated by a fluid-bed coater to control the release of DXM. The factors affecting to properties of pellets, such as diluent content, type and coating level of coating agents and plasticizers were studied in the present study. Polymethacrylate derivatives (Eudragit® RS PO and RL PO) were used for coating agents, and polyethylene glycol 6000 (PEG 6000), triethyl citrate (TEC) and castor oil were as plasticizers. To evaluate the properties of prepared pellets, the size of prepared pellets was investigated by sieve analysis technique and the morphology of pellets was evaluated by scanning electron microscopy. Through the dissolution test, factors that have an effect on the dissolution of the drug were evaluated. As the content ratio of microcrystalline cellulose (MCC) had increased, the dissolution was proportionally sustained. Eudragit® RS PO had more marked sustaining effect on the dissolution rate than Eudragit® RL PO, and the effect was more pronounced with the increased coating level. PEG 6000 was an appropriate plasticizer for DXM pellets, and increasing the content of PEG 6000, was also slightly decreasing the dissolution rate.
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Conzo G, Musella M, Corcione F, De Palma M, Ferraro F, Palazzo A, Napolitano S, Milone M, Pasquali D, Sinisi AA, Colantuoni V, Santini L. Laparoscopic adrenalectomy, a safe procedure for pheochromocytoma. A retrospective review of clinical series. Int J Surg 2012; 11:152-6. [PMID: 23267853 DOI: 10.1016/j.ijsu.2012.12.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 12/17/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND Minimally invasive adrenalectomy for pheochromocytoma (PCC) is a complex surgical procedure especially because of the haemodynamic instability due to the excessive secretion of cathecolamines, which may result in a considerable risk of conversion and complications. AIM By a multicentric retrospective study, the authors reported the results of laparoscopic adrenalectomies in patients operated for adrenal pheochromocytomas with the aim of investigating the role of the laparoscopic approach in managing adrenal disease. METHODS Sixty patients, preoperatively treated with a selective alpha1-blocker, underwent 61 laparoscopic adrenalectomies for PCC smaller or larger than 6 cm - group A (≤6 cm), group B (>6 cm). We compared the two groups of patients analyzing haemodynamic instability, operative time, conversion rate, incidence of complications, length of hospital stay and medium and long-term outcomes. RESULTS In 23 cases tumor was >6 cm in diameter. Average operative time was 165 min, with a 5% conversion rate. There was no mortality and morbidity rate was 8.3%. Intraoperative hypertensive crises were registered in 15% of patients, whereas 5/60 patients had hypotensive crises. After comparing the two groups of patients, no statistically significant differences in terms of haemodynamic instability, operative time, conversion rate, morbidity and length of hospital stay were observed. CONCLUSIONS As a surgical treatment of pheochromocytomas, laparoscopic adrenalectomy is an effective and safe approach, in selected cases even for PCCs >6 cm in diameter, although patients with such large tumors may have a higher conversion rate and more intraoperative hypertensive crises. Preoperative selective adrenergic blockade does not prevent intraoperative hypertensive crises, but by facilitating the pharmacological management of the perioperative haemodynamic instability, may avoid the onset of major adverse cardiovascular complications.
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Affiliation(s)
- Giovanni Conzo
- Department of Anaesthesiology, Surgical and Emergency Science, VII Division of General Surgery, Second University of Naples, Via Gen. Giordano Orsini 42, 80132 Naples, Italy.
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Clarifying the role of preoperative α-blockade in pheochromocytoma? J Hypertens 2012. [DOI: 10.1097/hjh.0b013e328351c43d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Clinical expression of phaeochromocytoma may involve numerous cardiovascular manifestations, but usually presents as sustained or paroxysmal hypertension associated with other signs and symptoms of catecholamine excess. Most of the life-threatening cardiovascular manifestations of phaeochromocytoma, such as hypertensive emergencies, result from a rapid and massive release of catecholamines from the tumour. More rarely, patients with phaeochromocytoma present with low blood pressure or even shock that may then precede multisystem crisis. Sinus tachycardia, with palpitations as the presenting symptom, is the most prevalent abnormality of cardiac rhythm in phaeochromocytoma, but tumours can also be associated with more serious ventricular arrhythmias or conduction disturbances. Reversible dilated or hypertrophic cardiomyopathy are well established cardiac manifestations of phaeochromocytoma, with more recent attention to an increasing number of cases with Takotsubo cardiomyopathy. This review provides an update on the cause, clinical presentation and treatment of the cardiovascular manifestations of phaeochromocytoma. As the cardiovascular complications of phaeochromocytoma can be life-threatening, all patients who present with manifestations that even remotely suggest excessive catecholamine secretion should be screened for the disease.
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